15 Ann. psychophysiol. ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| https://doi.org/10.29052/2412-3188.v8.i1.2020.15-23 Original Article Association between satisfaction with life and caregiver burden, among psychiatric patients Farkhanda Emad1, Saima Masoom Ali2, Farhan Ishaque3, Aftab Ahmed Mirza1, Hayatullah khalid4 & Abid Kamal Ansari5 1Sindh Institute of Physical Medicine & Rehabilitation, Karachi-Pakistan. 2Department of Psychology, University of Karachi, Karachi-Pakistan. 3Dow Institute of Physical Medicine & Rehabilitation, Dow University of Health Sciences, Karachi-Pakistan. 4Multan College of Physiotherapy, Multan Medical & Dental College, Multan-Pakistan. 5College of Physiotherapy, Jinnah Postgraduate Medical Centre, Karachi-Pakistan. Abstract Background: People who are dealing with psychological disorders are not able to take care of themselves; therefore, their family has to take care of them. While dealing with psychological issues is itself difficult for their family members. Schizophrenia and Bipolar disorder are psychological severe disorder that has a considerable influence not only in the patient but also for the entire family. This study aims to determine a relationship between life satisfaction and caregiver burden among caregivers of patients suffering from psychiatric illness. Methodology: We started the research after approval from the board of study and prior consent from the psychiatric hospitals' higher authorities and rehabilitation centers in Karachi. The authorities demonstrated the research objectives, the consent letter, and the questionnaire to be filled by the researcher. Zarit Burden Interview Scale (ZBIS) and Satisfaction with Life Scale (SWLS) (Pavot & Diener) were used. The sample size of this study was 170 psychiatric patients. Psychiatric patients were divided into schizophrenia disorder (n=85) and bipolar disorder (n=85). Results: The result indicates that the caregiver burden is the predictor of satisfaction with life in patients with bipolar disorders. It also shows in results that there was a significant difference among the different levels of the duration of illness on the variable of caregiver burden scale and satisfaction life scale among the caregivers of patients with schizophrenia and bipolar disorders. Further, findings indicate significant differences between males' and females' caregivers of psychiatric patients on the variable of caregiver burden and satisfaction with life scale. Conclusion: We concluded that caregiver burden significantly affects the mental health of the caregivers of patients with psychiatric disorders. Also, caregivers of people who are mentally ill patients suffer a lot of burdens. Therefore, interventions that can assist them, such as providing them with a support system and counselling services, must be created. Keywords Caregiver Burden, Patients, Schizophrenia, Bipolar, Life Satisfaction. Citation: Emad F, Ali SA, Ishaque F, Mirza AA, Khalid H, Ansari AK. Association between satisfaction with life and caregiver burden, among psychiatric patients. APP.2021; 8(1):15-23 Corresponding Author Email: farhan.ishauqe@duhs.edu.pk.com DOI: 10.29052/2412-3188.v8.i1.2021.15-23 Received 30/12/2020 Accepted 10/05/2020 Published 01/06/2021 Copyright © The Author(s). 2021 This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The author(s) received no specific funding for this work. Conflicts of Interests: The authors have declared that no competing interests exist. https://doi.org/10.29052/2412-3188.v8.i1.2020. http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) http://creativecommons.org/licenses/by/4.0/) 16 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 8 Issue 1 Introduction The health of caregivers got challenged by offering treatment to family members suffering from prolonged illness. When the family member has a significant psychological disorder, the role of providing treatment becomes more daunting as the stigma of mental illness contributes to this strain of caring. The caregiver's burden has similar characteristics, either physical or mental conditions, or caregivers also experience anxiety and depressive disorders and many economic and occupational symptoms. However, through the signs and social response to them, various pathologies have particular effects on caregivers, so these distinctions create unique needs for patient care1. This study's objective was to determine the association of satisfaction with life and caregiver burden among patients with schizophrenia disorder. It aimed to estimate any gender differences on the variables of caregiver burden and satisfaction with life scale among the caregivers of patients with psychiatric disorders. Patients suffering from extreme mental disorders develop a heavy reliance on caregivers, primarily because of their disease's significant impairment. This dependence and responsibility for providing care add to their misery of caregivers' quality of life, affecting their health, employment, socializing, and relationships2. In terms of its impact, the literature distinguishes burden as objective (e.g. disturbance in the life of caregivers in terms of household routine, social activities and financial/employment problems) and subjective (emotional distress endured by caregivers, e.g. depression, anxiety, frustration, shame, loss, stigma and rejection3. Besides, the socio-demographic factors and disease-related aspects of care recipients and caregivers considered contributing to the workload of the caregiver4, 5. It may neglect their well-being and other social and personal needs of caregivers, which decreases their ability to cope effectively with care demands. Most psychiatric disorders also put a heavy burden on caregivers. Still, of these disorders, schizophrenia attracts more attention because of the deterioration in the patient's person and social functioning and the symptoms that affect the caregivers' quality of life and the severity and early breakout of the disorder6. Past research indicates that the burden of care should be categorized as an objective burden and a subjective burden, as factors that relate to caregivers' physical and mental health and the effect of these types of burden7. Burden refers to the inputs pertaining to caregiving activities that could be determined by the time spent on caregiving and the functional level of care recipients. The subjective burden focuses on the self-perceived impact on caregivers of the objective burden8. The critical correlation between objective and subjective treatment among family dementia caregivers explored in several studies identifying higher objective burdens linked to higher subjective burdens9, 10. The physical and mental well-being, social relationships, and caregivers' financial life are impressed by the family caregiver burden11,12. It also correlates with psychological morbidity, lower leisure time, workload, and caregiver burnout13. Due to patients' behaviour and a negative attitude towards the patient, they often feel frustration, rage, humiliation, anxiety, sadness, and stress14, 15. Schizophrenia is one of the ten disorders contributing to the loss of capacity in individuals, based on research carried out by the World Health Organization. Schizophrenia is a psychological condition that is profoundly debilitating and persistent, affecting all significant aspects of a patient's life. The 17 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 8 Issue 1 World Health Organization reports that 29 million people worldwide have been affected by schizophrenia. The prevalence of psychotic disorders is approximately 0.89 percent in an epidemiological analysis of mental disorders done in Iran, with schizophrenia being 0.6 percent. Methodology The quasi-experimental study was design to draw the association between satisfaction with life and caregiver burden among psychiatric patients. A sample size of 170 psychiatric patients was used for data collection after the purposive sampling technique. The study's objective, operation, and material got approval from the Board of Advanced Studies and Research. The University of Karachi and psychiatric hospitals and rehabilitation centers of Karachi. The clinical psychologist double- checked the data by following the DSM-5 guidelines (APA, 2013), then was interviewed them and their caregivers. Schizophrenic (N=85) and bipolar disorder (N=85), further classified as patients with psychiatric disease. We excluded all the patients who had any psychiatric or medical illness as co-morbidity, the patients who had been meeting the research norms but they are not taking any medicine, or therapeutic intervention, all the intellectually challenged and physically disabled population. One caregiver against each patient participated in the study, and those who have had the prime accountability to look after the patients were contained in the study. Caregivers who were experiencing any kind of psychiatric disorder, intellectually challenged or any medical disease that can significantly impact the cognitive level or psychological function were excluded from the study. For the current study, a three-part survey questionnaire comprising the first part consists of informed consent from the caregivers. The second part included demographic variables, and in the third part, the study questionnaire was administered. Zarit Burden Interview Scale (ZBIS) and Satisfaction with Life Scale (SWLS) were used. Regression analysis, t-test and analysis of variance tests are also used to find the study's best results. The data were statistically analyzed using SPSS version 20.0. Result The demographic characteristics of the patient and caregivers are given in table 1 & 2. Table 1: Demographic characteristics of patients (N= 170) Variables Categories n(%) Gender Male 75(44.1) Female 95(55.9) Qualification Primary 14(8.2) Middle 16(9.4) Matric 34 (20.0) Intermediate 39(22.9) Graduate 22(12.9) Masters 22(12.9) Uneducated 23(13.5) Marital Status Single 94(55.3) Married 59(34.7) 18 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 8 Issue 1 Divorced 17 (10.0) Family System Joint 91(53.5) Nuclear 79(46.5) Diagnosis Schizophrenia 85(50.0) Bipolar 85(50.0) Duration of illness 0-5 years 54(31.8) 6-10 years 60(35.3) 11-15 years 56(32.9) Nature of Treatment Medication 107(62.9) Psychotherapy 16(9.4) Combined 47(27.6) Treatment Setting OPD 139(81.8) IPD 31(18.2) Table 2: Demographic characteristics of caregivers (n=170). Variables Categories n(%) Gender Male 95(55.9) Female 75(44.1) Qualification Primary 5(3.3) Middle 6(3.5) Matric 9(5.3) Intermediate 31(18.2) Graduate 21(12.4) Masters 39(22.9) Uneducated 27(15.9) Occupation Employed 51(30.0) Unemployed 96(56.5) Housewife 13(7.6) Student 10(5.9) Qualification Primary 6(3.5) Middle 9(5.3) Matric 31(18.2) Intermediate 21(12.4) Graduate 39(22.9) Masters 27(15.9) Uneducated 37(21.8) 19 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 8 Issue 1 The result indicates that the caregiver burden is the predictor of satisfaction with life in the caregivers of patients with schizophrenia disorders [R2, .554; F (1.84) = 36.711, p<0.000]. Table 3: Linear Regression Analysis and Analysis of Variance Statistics of life satisfaction scale with caregiver Burden scale Model R R2 Adj. R2 SS df MS F p- valve (Constant) Caregiver Burden .554a .307 .298 1912.035 1 1912.035 36.711 0.000 4322.953 83 52.084 6234.988 84 a. Dependent Variable: Satisfaction with life scale b. Predictors: (Constant), Caregiver Burden Scale Further, it was found that the caregiver burden is a strong predictor of satisfaction with life in the caregivers of patients with schizophrenia disorders (β=.554, p<0.001). Table 4: Coefficient statistics of life satisfaction scale and caregiver Burden scale among the caregivers of patients with schizophrenia Model Unstandardized Standardized T p-value 95% CI Β SE Beta LB UB (Constant) 29.912 2.299 13.008 .000 25.339 34.486 SWLS -.259 .043 -.554 -6.059 .000 -.344 -.174 a. Dependent Variable: Satisfaction with Life Scale; SWLS=Satisfaction with Life Scale, SE= Standard Error, LB= Lower Bond, UB=Upper Bon The result indicates that the caregiver burden is the predictor of satisfaction with life in the caregivers of patients with bipolar disorders [R2, .701; F (1.84) = 79.97, p<0.000]. Table 5: Analysis of Variance Statistics of life satisfaction scale with caregiver Burden scale among the caregivers of patients with bipolar disorder Model R R2 Adj.R2 SS df MS F p-valve (Constant) Caregiver Burden .701a .491 .485 3200.959 1 3200.959 79.975 0.000b 3322.029 83 40.024 6522.988 84 a. Dependent Variable: Satisfaction with life scale b. Predictors: (Constant), Caregiver Burden Scale Results indicate that there were a significant difference among the different level of the duration of illness on the variable of caregiver burden scale among the caregivers of patients with schizophrenia and bipolar disorders [F (2,169) = 396.810; p< .000] 20 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 8 Issue 1 Table 6: Variance statistics for the duration of illness with caregiver burden among the caregivers of patients with schizophrenia and bipolar disorders Variable SS df MS F p-valve Between Groups 54890.810 2 27445.405 396.810 0.000 Within Groups 11550.579 167 69.165 Total 66441.388 169 Discussion The burden of caregivers is the major predictor of life-scale satisfaction among schizophrenia disorder patients. Getting a member of the family with schizophrenia disorganizes the familiar dynamics according to the function theory. Role- conflicts arise when the caregiver itself is made up of conflicting and incompatible specifications16. Role-conflicts have a range of adverse effects on caregivers, such as physical difficulties, fatigue, burn-out, anxiety and other mental disorders17. Expressed emotion is a measure of the family environment that focuses on how the relatives of the psychiatric patient talk about the patient spontaneously15. In patients with mental illness, such as schizophrenia, high levels of expressed emotion in the home may worsen the prognosis and may serve as a potential risk factor for developing psychiatric disorders18. Also, this study showed that married caregivers had greater stress levels than unmarried caregivers. The potential cause may be the extra burden of infants, caregivers, and other family members, leading to higher stress levels. The coping mechanisms of caregivers need to be considered to overcome pressures, as they affect the day-to-day functioning of caregivers19,20. As with schizophrenia, the caregivers of bipolar patients have similar degrees of disrupted habits. Both conditions affect families and need the same degree of caregiver treatment for their stability. But the level of stress and frustration perceived by bipolar caregivers due to violent and aggressive behaviour is high. These findings are not in line with previous studies that we refer to in this report. It showed that the caregivers of schizophrenia had higher stress levels than those of another group21. Regression analysis found that the clinical function of the patient better explained the variance observed in the FEIS variables as opposed to the characteristics of the patient, which explained no more than 8.5 percent of the variance, while caregiver characteristics explained 11.7 percent variance in the bipolar disorder category for satisfaction with services. Past studies have confirmed the correlation between the stress of caregivers and symptoms of severe mental disorders. In patients with mental illness, the disease's length has a significant difference in satisfaction with the life scale. It was noticed that caregivers with two or more years of caregiver experience had a higher degree of caregiver pressure than those with 1-6 months and 1-2 years of care length. Similar to the study results, it was found that longer care durations were positively associated with higher caregiver pressures22. Three key factors associated with caregiver frustration with the condition, in general, were identified in this analysis included inadequate psychosocial functioning of patients, insufficient use of medication and 21 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 8 Issue 1 rehabilitative services by patients, and living with the patient. The frustration of caregivers with psychiatric treatment for patients is distinct from their general dissatisfaction in life. If the patients had severe psychotic symptoms or weak life-grip maintenance, caregivers were unhappy with facilities. The stress and frustration of the caregiver are often correlated with psychiatric facilities. The most fundamental aspect that can ensure clinicians' satisfaction is therapeutic interventions that could enhance the functional status of patients and appropriate medication23. Past research has shown that treatment is a significant public health challenge that should not be overlooked combined with patient medication and therapeutic facilities24, 25. In this research, it was found that most caregivers of schizophrenia patients are happy with their condition and psychiatric services. In Finland, 20-30 percent of caregivers in psychiatric treatment, recovery, and drug care for patients with low functional status and unmet needs are unhappy and depressed. In reality, these caregivers need more participation in therapies, data, support, and therapy. So, caregivers should also be adequately evaluated. Caregivers can only serve as a resource in inpatient care if they obtain adequate support26,27. Conclusion It is painful to live with a psychiatric illness, both for the patients and the families. The family members coping with such patients were seen to have ranked lower on the scale of life satisfaction. It was also seen that, as opposed to males, female care providers had lower scores on the life satisfaction scale. Family support is really important when coping with any disorder, whether mental or physical. But when an individual is dealing with a mental illness, the need to establish and sustain interpersonal relationships, take care of oneself, complete schooling, and maintain jobs interferes with one's ability. When supporting their patients, counsellors or therapists can also have some counselling for their family members, which may help family members understand themselves and their loved ones. And they should clarify that they should not neglect their own needs and demands when taking the caregiver position. Acknowledgement The author would like to acknowledge Dr. Saima Masoom Ali, Assistant Professor, University of Karachi, for her valuable advice and timely support throughout this research. Sincere thanks to Dr. Farhan Ishaque Khan, Assistant Professor at Institute of Physical Medicine & Rehabilitation Dow University of Health Sciences, for rendering extraordinary support. I would like to extend the deepest appreciation to Dr. AQ Khan Centre Institute of Behavioral Sciences, Gulshan Psychiatrist Hospital, Addicare Rehabilitation Centre, who cooperates and helping in data collection from their respective organizations. References 1. Alzahrani SH, Fallata EO, Alabdulwahab MA, Alsafi WA, Bashawri J. Assessment of the burden on caregivers of patients with mental disorders in Jeddah, Saudi Arabia. BMC psychiatry. 2017;17(1):202. 2. American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5™ (5th edition) 2013. American Psychiatric Publishing, Inc. 3. Asarnow JR, Tompson M, Woo S, Cantwell DP. Is expressed emotion a specific risk factor for depression or a nonspecific correlate of psychopathology?. J Abnorm Child Psychol. 2001;29(6):573-583. 22 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 8 Issue 1 4. Ayalew M, Workicho A, Tesfaye E, Hailesilasie H, Abera M. Burden among caregivers of people with mental illness at Jimma University Medical Center, Southwest Ethiopia: a cross-sectional study. Ann. Gen. Psychiatry. 2019;18(1): Article number: 10. 5. Bekdemir A, Ilhan N. Predictors of caregiver burden in caregivers of bedridden patients. J Nurs. Res. 2019;27(3):e24. 6. Butzlaff RL, Hooley JM. Expressed emotion and psychiatric relapse: a meta-analysis. Arch. Gen. Psychiatry. 1998;55(6):547-552. 7. Cao Y, Yang F. Objective and subjective dementia caregiving burden: The moderating role of intrinsic justice reasoning and social support. Int. J. Environ. Res. Public Health. 2020;17(2):455. 8. Caqueo-Urízar A, Gutiérrez-Maldonado J, Ferrer-García M, Darrigrande-Molina P. Burden of care in Aymara caregivers of patients with schizophrenia. Revista de Psiquiatría y Salud Mental (English Edition). 2012;5(3):191-196. 9. Cetinkaya F, Karadakovan A. Investigation of care burden in dementia patient caregivers. Turk J Geriatr. 2012;15(2). 10. Corcoran MA. Gender differences in dementia management plans of spousal caregivers: implications for occupational therapy. Am J Occup Ther 1992; 46: 1006- 1012. 11. Fadaei F, Qorbani M, Asayesh H, Rahmani Anaraki M. The effect of poetry therapy group on communicational skills of a schizophrenic patient. J Urmia Nurs Midwifery Faculty. 2016;13(11):919–927. 12. Gater A, Rofail D, Tolley C, Marshall C, Abetz-Webb L, Zarit SH, Berardo CG. “Sometimes it’s difficult to have a normal life”: results from a qualitative study exploring caregiver burden in schizophrenia. Schizophr. Res. Treatment. 2014; Article ID 368215. 13. Jagannathan A, Thirthalli J, Hamza A, Nagendra HR, Gangadhar BN. Predictors of family caregiver burden in schizophrenia: Study from an inpatient tertiary care hospital in India. Asian J Psychiatr. 2014; 8:94–98. 14. Jeyagurunathan A, Sagayadevan V, Abdin E, Zhang Y, Chang S, Shafie S, Rahman RF, Vaingankar JA, Chong SA, Subramaniam M. Psychological status and quality of life among primary caregivers of individuals with mental illness: a hospital based study. Health Qual. Life Outcomes. 2017;15(1):106. 15. Kate N, Grover S, Kulhara P, Nehra R. Relationship of caregiver burden with coping strategies, social support, psychological morbidity, and quality of life in the caregivers of schizophrenia. Asian J Psychiatr. 2013; 6(5):380–388. 16. Kızılırmak B, Küçük L. Care burden level and mental health condition of the families of individuals with mental disorders. Arch Psychiatr Nurs. 2016;30(1): 47–54. 17. Millier A, Schmidt U, Angermeyer MC, Chauhan D, Murthy V, Toumi M, Cadi- Soussi N. Humanistic burden in schizophrenia: a literature review. J Psychiatr Res. 2014; 54:85 18. Reinhard SC, Gubman GD, Horwitz AV, Minsky S. Burden assessment scale for families of the seriously mentally ill. Eval Program Plann.1994;17(3):261-269. 19. Nallapaneni NR, Yendluri P, Paritala CB, Racharla BN. A study of caregiver burden in bipolar affective disorder. J. Evol. Med. Dent. Sci. 2015;4(49):8499-8516. 20. Reinhard SC, Gubman GD, Horwitz AV, Minsky S. Burden assessment scale for families of the seriously mentally ill. Eval Program Plann. 1994;17(3):261-269. 21. Rössler W, Salize HJ, van Os J, Riecher- Rössler A. Size of burden of schizophrenia and psychotic disorders. Eur Neuropsychopharmacol. 2005; 15(4):399–409. 22. Sharif F, Shaygan M, Mani A. Effect of a psycho-educational intervention for family members on caregiver burdens and psychiatric symptoms in patients with schizophrenia in Shiraz, Iran. BMC psychiatry. 2012; 12(1):48. 23. Sharma N, Chakrabarti S, Grover S. Gender differences in caregiving among family- caregivers of people with mental illnesses. World J Psychiatr. 2016;6(1):7-17. 24. Siddiqui S, Khalid J. determining the caregivers’ burden in caregivers of patients with mental illness. Pak J Med Sci. 2019;35(5):1329-1333. 25. Tamizi Z, Fallahi-Khoshknab M, Dalvandi A, Mohammadi-Shahboulaghi F, Mohammadi 23 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 8 Issue 1 E, Bakhshi E. Defining the concept of family caregiver burden in patients with schizophrenia: a systematic review protocol. Syst Rev. 2019;8(1):1-6. 26. Van Wijngaarden BO, Schene AH, Koeter M, Vázquez-Barquero JL, Knudsen HC, Lasalvia A, Mccrone P, Epsilon Study Group. Caregiving in schizophrenia: development, internal consistency and reliability of the Involvement Evaluation Questionnaire– European Version: Epsilon Study 4. Br J Psychiatry. 2000;177(S39):s21-7. 27. Yu Y, Liu ZW, Tang BW, Zhao M, Liu XG, Xiao SY. Reported family burden of schizophrenia patients in rural China. PloS one. 2017;12(6):e0179425. https://crossmark.crossref.org/dialog/?doi=10.29052/2412-3188.v8.i1.2021.15-23